Research: A Fast Track for Initiating HIV Treatment for Pregnant Women
Last week we were delighted to host a talk by Foundation International Leadership Awardee Dr. Landon Myer. He spoke by teleconference from South Africa to give an update on his Foundation-supported project, “Strategies for the rapid initiation of antiretroviral therapy in pregnancy.”
Dr. Myer is an associate professor in the School of Public Health and Family Medicine at the University of Cape Town. He’s also a trained epidemiologist and medical doctor working on HIV and maternal child health at the Desmond Tutu HIV Foundation.
He was chosen by the Foundation last year for a three-year International Leadership Award, generously funded by the Stavros Niarchos Foundation.
Dr. Myer’s research is focused on three primary objectives:
- To identify barriers to initiating HIV-positive pregnant women on treatment through operations research around new interventions
- To model different strategies to promote early initiation of treatment in pregnancy
- To develop and pilot interventions to promote optimal treatment initiation in pregnant women
- The majority of his research and training activities to date have taken place within the former township of Gugulethu, outside of Cape Town. There he focused on developing and pilot-testing an intervention for the rapid initiation of antiretroviral therapy (ART) in pregnant women – referred to as the “fast track” intervention.
In South Africa, approximately 30% of women seeking antenatal care in the public sector are HIV-positive, and there are 300,000 pregnancies in HIV-positive women each year.
Data show that the longer a pregnant woman is on treatment, the less likely she is to pass HIV on to her baby. This makes identifying and reducing delays in starting therapy especially important.
Data show that pregnant women who are on treatment longer during their pregnancy are less likely to pass HIV on to their baby. (Photo: EGPAF/Jon Hrusa)
The “fast track” intervention was intended to reduce the most common delays for starting ART during pregnancy, and included use of a rapid, point-of-care CD4 test to identify pregnant women who are eligible for treatment. In South Africa, that includes women whose CD4 cell count is below 350.
These tests were administered as soon as possible after women tested positive on standard rapid HIV tests. If they were identified as eligible for ART, they were provided with intensive patient education and ART counseling on the same day. They were also initiated on therapy the same day when possible.
Concurrently, psychosocial support and continuing education programs were provided, as well as clinical and laboratory monitoring based upon the national guidelines for ART in South Africa.
From his first year of work, Dr. Myer presented valuable lessons and insights from his pilot program, including:
- The use of point-of-care CD4 testing was feasible and acceptable to patients, reducing the number of clinic visits and lab tests, and allowing ART to be started much sooner.
- Integration of ART services in maternal and child care (MCH) settings through training and support to midwives is feasible and critical to rapid initiation of ART for pregnant women.
- Providing counseling and support to prepare women for ART initiation is important, but can be done well without delaying the start of therapy.
Through the pilot study and concurrent operational research, his team determined that treatment-eligible, pregnant women referred for ART late in their pregnancies were significantly less likely to start treatment before delivery of their babies.
The data gathered thus far appear to support the “fast track” approach for early ART initiation in pregnancy – and Dr. Myer has already presented his findings at this year’s Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle.
More research is needed to determine if the “fast track” method is feasible within larger-scale programs of antenatal care and HIV care and treatment that are more representative of the health care settings in southern Africa.
In the next year, Dr. Myer will focus on developing a new avenue of research and intervention on keeping HIV-infected women in care and treatment services after they give birth.
Preliminary analyses have suggested HIV-positive women who began treatment during pregnancy are often lost to follow-up after they give birth, but still require services in the post-partum period.
It is our hope that Dr. Myer’s research will help inform national programs about strategies to initiate ART therapy early in HIV-infected pregnant women.
The outcomes could help reduce mother-to-child transmission of HIV, improve loss to follow-up for HIV-positive mothers, and maintain the health of both mother and child in the years to come.
Chris Hudnall is the Foundation’s Senior Program Coordinator for Research in Los Angeles